JAN
JOURNAL OF ADVANCED NURSING
REVIEW PAPER
Hope, older adults, and chronic illness: a metasynthesis of qualitative
research
Wendy Duggleby, Deborah Hicks, Cheryl Nekolaichuk, Lorraine Holtslander, Allison Williams, Thane
Chambers & Jeannette Eby
Accepted for publication 28 November 2011
Correspondence to W. Duggleby:
e-mail: [email protected]
Wendy Duggleby PhD RN AOCN
Nursing Research Chair Aging and Quality of
Life
Faculty of Nursing, University of Alberta,
Edmonton Alberta T6G 2G3,
Canada
Deborah Hicks MA MLIS
Doctoral Student
University of Alberta, Edmonton Alberta,
Canada
Cheryl Nekolaichuk PhD RPsych
Associate Professor
Department of Oncology, University of
Alberta
and Psychologist
Palliative Care Program, Grey Nuns
Community Hospital, Edmonton Alberta,
Canada
Lorraine Holtslander PhD RN
Assistant Professor
College of Nursing
University of Saskatchewan, Saskatoon
Saskatchewan, Canada
Allison Williams PhD CIHR OWHC/IGH
Mid Career Scientist, Associate Professor
School of Geography and Earth Sciences,
McMaster University, Hamilton Ontario,
Canada
DUGGLEBY W., HICKS D., NEKOLAICHUK C., HOLTSLANDER L., WILLIAMS A.,
C H A M B E R S T . & E B Y J . ( 2 0 1 2 ) Hope, older adults, and chronic illness:
a metasynthesis of qualitative research. Journal of Advanced Nursing 68(6), 1211–
1223. doi: 10.1111/j.1365-2648.2011.05919.x
Abstract
Aim. To report a metasynthesis review of qualitative research studies exploring the
hope experience of older persons with chronic illness.
Background. Hope is a psychosocial resource used by persons to deal with their
chronic illness experience.
Data sources. A comprehensive search of multiple databases for studies of the hope
experience (published 1980–2010) was completed. Inclusion criteria were included
qualitative studies of the hope experience of persons (all genders; mean age 60 years
and older), with chronic illnesses, and publications in any language and country.
Review methods. The metasynthesis followed four procedural steps: (a) comprehensive search, (b) quality appraisal, (c) classification of studies, and (d) synthesis of
findings.
Results. Twenty studies were included in the metasynthesis representing research
from a variety of different countries and populations with differing medical diagnoses.
The characteristics of hope included: (a) dynamic or situational nature, (b) multiple
co-existing types, (c) objects that were desirable realistic possibilities, (d) futurefocused, and (e) involvement of choice/will. Hope as ‘transcending possibilities’
represented the integration of two processes of transcendence and positive reappraisal. Reaching inwardly and outwardly and finding meaning and purpose were
sub-processes of transcendence, whereas re-evaluating hope in light of illness and
finding positive possibilities were sub-processes of positive reappraisal.
Conclusions. The concept of hope may differ for older adults vs. younger adults in its
interaction with suffering. Resources for hope are both internal and external. Finding
meaning and positive reappraisal are important strategies to help older adults with
chronic illness maintain their hope.
Keywords: chronic illness, hope, metasynthesis, nursing, older adults, nurses, nursing
continued on page 2
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W. Duggleby et al.
Thane Chambers MLIS
Research Librarian
Research Office
Faculty of Nursing University of Alberta,
Edmonton Alberta, Canada
Jeannette Eby BA
MA Candidate
School of Geography and Earth Sciences,
McMaster University, Hamilton, Ontario,
Canada
Introduction
The World Health Organization (2010) suggests that chronic
disease has a major impact on the quality of life of
individuals. With the increasing numbers of persons with
chronic disease and persons over the age of 65 worldwide,
there is an escalating need to find ways to support older
persons with chronic illness. Hope is an important psychological resource for persons with chronic illness and has been
described as essential to life (Eliott & Olver 2009). It has
been defined as a ‘multidimensional dynamic life force
characterized by a confident yet uncertain expectation of
achieving future good which, to the hoping person, is
realistically possible and personally significant’ (Dufault &
Martocchio 1985, p. 380). As a dynamic multidimensional
concept, hope changes over time and across important life
events, such as chronic illness and ageing.
Only a few hope interventions have been developed and
reported to have an important impact on the hope of older
adults with chronic illness (Staats 1991, Tollett & Thomas
1995, Duggleby et al. 2007). This may be because of the
complex multidimensional nature of hope that makes
conceptual clarification a challenge. The theories and conceptual models of hope vary significantly with respect to
how hope is conceptualized (Wiles et al. 2008) and have
been developed with different populations (Dufault &
Martocchio 1985, Farran et al. 1995, Morse & Doberneck
1995, Synder 2000, Duggleby & Wright 2005). For example, Synder’s theory of hope focuses on cognitive goal
setting, whereas Duggleby and Wright’s grounded theory
suggests that finding meaning and purpose is an important
process of hope.
Although studies of hope of persons with chronic illness
support the importance of hope for this population, their
findings also vary significantly in terms of how hope is
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conceptualized (Wiles et al. 2008). This variation might be
the result of many factors, including the diversity of the
illness experience, and the methodological approach used to
study the hope experience. For example, the hope experience
of a person with terminal cancer appears to differ from
a person with a non-terminal disease (Perakyla 1991).
Approaches chosen to study the hope experience also reflect
a difference in the conceptualization of hope. Phenomenological studies of the hope experience of persons with
terminal illness describe the essence of the experience (i.e.
Benzein et al. 2001), although those using grounded theory
view hope as a process and describe the processes of hope (i.e.
Duggleby & Wright 2005). Whatever the reason there is a
lack of clarity of the concept of hope in persons with chronic
illness.
Metasynthesis is a method that brings together qualitative
exploratory studies to enhance their contribution to the
development of more formalized knowledge (Zimmer 2006).
Similar to other qualitative approaches, to understand hope
conceptually, the metasynthesis approach seeks diversity in
studies to explore how disparate findings are conceptually
related to each other and to clarify the defining and
overlapping attributes (Sandelowski & Barroso 2007). For
example, assumptions are not made that studies from
different cultures and contexts are the same; rather a
conceptual understanding of hope will include their diversities and similarities. The resultant conceptualization from
metasynthesis provides a global picture of the phenomenon
under study (Hammer et al. 2009).
Previous hope metasyntheses have explored hope and
expectations in people recovering from illness using narrative
analysis (Wiles et al. 2008), the meaning of hope with people
who were healthy and those who were ill in nursing research
(Hammer et al. 2009), the hope experience of family carers of
persons with chronic illness (Duggleby et al. 2010b) and
despair and hopelessness in the context of HIV (Kylma 2005).
All these published metasyntheses include studies of persons
with chronic illness (except for Duggleby et al. 2010b) with a
wide range of ages and not specifically considering hope in
older persons with chronic illnesses. Inclusion of studies of all
age groups ignores the physical, psychosocial, and spiritual
changes that occur with normal ageing. These changes
influence how older adults deal with chronic illnesses and
hope. Older persons rely on different methods of maintaining
hope than younger persons (Herth 1993, Duggleby & Wright
2005). Hope is one psychosocial resource older adults use to
cope with life’s adversities (Westburg 2003) and given the
complex construct of hope and the essential nature of hope to
older persons with chronic illness, it is important to develop
knowledge in this area.
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The review
Hope, older adults, and chronic illness
Abstracts, metasynthesis, and secondary analysis studies
were excluded.
Aim
The purpose of this metasynthesis review was to explore the
hope experience of older persons with chronic illness. The
specific aims were to identify qualitative research in this area,
and through synthesis of the study findings describe the
characteristics and processes of hope.
Design
This metasynthesis of qualitative research studies on hope of
older adults with chronic illness followed the procedures
outlined by Sandelowski and Barroso (2007). The procedural
steps included (a) a comprehensive search, (b) appraising
reports of qualitative studies, (c) classification of studies, and
(d) synthesis of the findings.
Search method
An experienced medical librarian searched nine databases for
research articles published from January 1980 – March 2010
using keywords and subject headings of hope, hopeless, and
despair. A qualitative and mixed methods study filter was
used. In each search a combination of subject headings,
keywords, and words in title were used as were search
strategies modified depending upon the database and the
controlled vocabularies available. The nine databases
searched included: OVID Medline In-Process & Other
Non-Indexed Citations, Medline, EBSCOhost CINAHL,
and ISI Science Citation Index Expanded chosen for their
coverage of health issues; OVID PsycINFO for its coverage of
the psychological literature; OVID Ageline for it coverage of
the older people; EBSCOhost ATLA Religion Database for
theological literature; CSA Sociological Abstracts and ISI
Social Sciences Citation Index for sociology; and Scopus for
its interdisciplinary coverage.
The team members then studied titles and abstracts of all
studies and identified those appropriate for the metasynthesis based on inclusion/exclusion criteria. Inclusion criteria
for the metasynthesis were (a) studies of the hope experience
of persons (all genders, mean age of 60 years and older)
with chronic illnesses, (b) studies published in any language
and country, (c) published peer-reviewed research studies,
(d) qualitative and/or mixed methods designs, and (e)
studies published between 1980 and 2010. Studies reporting
the hope experience of patients, families and/or healthcare
professionals were included if the hope experience of
persons with chronic conditions were also reported.
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Search outcome
Figure 1 outlines the search method and outcome. In total,
5232 citations were retrieved of which 2021 were duplicates.
After title and abstract screening, based upon the inclusion
criteria, 19 were included. One article was removed as it
reported findings from a study that was also published
elsewhere. One additional article was located by hand.
Authors of the studies were contacted and asked if they had
additional published, submitted or accepted publications that
they would be willing to share. Ten authors responded to the
request and one additional in press article was obtained,
which has since been published, for a total of 20 articles
published between 1985 – 2010. Of the 20, one article
written in Finnish and another in Japanese were translated
into English by researchers whose first language was Finnish
and Japanese and who were living in Finland and Japan,
respectively. These researchers/translators were also asked to
clarify and check their translations for accuracy through back
translation. Table 1 lists the included studies, and their
purpose, method, and quality appraisals.
Quality appraisal
The purpose of the appraisal was to become familiar with the
reports and to evaluate them for quality using the [Critical
Appraisal Skills Program (CASP) 1998]. The CASP provides a
standardized mechanism for appraising qualitative studies
using metasynthesis (Feder et al. 2006). It consists of 10
questions: two for screening out inapplicable studies and eight
about the research design, data collection and analyses, ethics,
reflexivity, and implications of qualitative studies. Using a
three-point rating system developed by (Feder et al.2006) a
score was calculated for each article for each of the CASP’s
eight questions. A weak score (one point) was assigned to
articles that offered little to no justification or explanation for a
particular issue (e.g. where, when, or how the data were
collected was not mentioned). A moderate score (two points)
was given to articles that addressed the issue but did not fully
elaborate on it (e.g. the justification for using constant
comparisons was presented but the procedure itself was not
explained). A strong score (three points) was assigned to
articles that extensively justified and explained the issue at
hand (e.g. the authors explained that semi-structured interviews were used, transcribed verbatim and modified part way
through the study, and then offered some sample interview
questions). For each article a score was calculated for all eight
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W. Duggleby et al.
Search terms: hopes, hopelessness, despair
9 database = 5232 abstracts
Excluded 2021
as duplicates
Included 3211
Abstracts and titles reviewed
Excluded 3192 not
meeting criterion
Included 19
Full articles reviewed
Included 18
Excluded one as
from same study
Hand search added one = 19
Contacted authors: one added = 20
20 total (one
Finnish, one
Japanese and 18
English)
Figure 1 Flow diagram of search.
questions and then totalled with a maximum score of 24. For
the 20 articles included, the mean CASP score was 18Æ83 with a
standard deviation of 2Æ98 (range of 13–23). The CASP was
used to describe the quality of the studies as one aspect of the
context for the metasynthesis findings. As recommended by
Sandelowski and Barroso (2007) articles were not excluded
based on the CASP score.
Data abstraction and synthesis
The findings of the studies were classified using Sandelowski
and Barroso’s (2007) classification system. The purpose of
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this procedure was to reveal the actual analytical work
performed (vs. what was stated). The stated methodological
approaches were: (a) 11 employing thematic/descriptive
analysis (Dufault & Martocchio 1985, Herth 1993, Daly
et al. 1999, Weil 2000, Bays 2001, Buckley & Herth 2004,
Davison & Simpson 2006, Matsumoto & Doi 2006, Mattioli
et al. 2008; Sanatani et al. 2008, Mok et al. 2010), (b) five
using phenomenology (Flemming 1997; Kylma 1998, Forbes
1999, Benzein et al. 2001, Milne et al. 2009), (c) three
discourse analysis (Eliott & Olver 2007, 2009, Duggleby
et al. 2010a), and (d) one employing grounded theory
(Duggleby & Wright 2005). Using Sandelowski and
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To illuminate the meaning of the lived
experience of hope in patients with cancer in
palliative home care
To explore the meaning of hope of terminally
ill patients
Benzein et al. (2001) (Sweden)
Use phenomenology and concept mapping to
build a model of hope in older adults facing
chronic illness
To understand hope and identify strategies
that older persons use to regain or maintain
hope so as to develop environments within
which hope can be fostered
Forbes (1999) (USA)
Herth (1993) (USA)
Flemming (1997) (USA)
To examine unsolicited hope-talk and to
assess the impact of dominant cultural beliefs
about hope
To explore the meaning of hope to patients
with cancer who are receiving palliative care
To explore the current societal discourse on
hope and the hope of older terminally ill
patients with cancer, their important others,
and their primary nurse
To describe, using a grounded theory
approach, the processes by which palliative
patients live with hope
To examine the use of hope, as spontaneously
used in interviews with patients with cancer
Eliott and Olver (2009) (Australia)
Eliott and Olver (2007) (Australia)
Duggleby and Wright (2005) (Canada)
Duggleby et al. (2010a) (Canada)
Dufault and Martocchio (1985) (USA)
Davison and Simpson (2006) (Canada)
Daly et al. (1999) (Australia)
To explore the meaning of the experience of
hope for survivors of acute myocardial
infarction
To understand hope in the context of advance
care planning from the perspective of
patients with end-stage renal disease
To describe hope and its spheres and
dimensions
To explore the phenomenon of hope in older
adults who have experienced a stroke
Bays (2001) (USA)
Buckley and Herth (2004) (UK)
Purpose
Source/country
Table 1 Summary of articles included in the metasynthesis.
Thematic/descriptive
Semi-structured interviews; HHI with 10 persons
with unspecified diagnosis
Grounded theory
Open-ended interviews with 10 palliative
patients with cancer
Discourse analysis
Semi-structured interviews with 28 advanced
patients with cancer
Discourse analysis
Semi-structured interviews with 28 advanced
patients with cancer
Phenomenology
Semi-structured interviews with 4 advanced
cancer
Phenomenology/concept mapping
Interviews and concept mapping
Mixed methods
BDF, HHI, and interviews with 16 persons with
multiple diagnosis
Thematic/descriptive
In-depth interviews with 8 persons with acute
myocardial infarction
Thematic/descriptive
Open-ended interviews with 19 patients with
end-stage renal disease
Thematic/descriptive
Semi-structured interviews and observations
with 35 patients with cancer
Discourse analysis
Interviews with three palliative patients with
cancer
Thematic/descriptive
Open-ended interviews with nine persons who
had a stroke
Phenomenology
Interviews with 11 palliative care patients
Method/data collection
Thematic survey CASP = 21
Conceptual Thematic Survey
CASP = 16
Thematic survey CASP = 16
Interpretive CASP = 22
Interpretive CASP = 20
Interpretive CASP = 21
Interpretive CASP = 20
Interpretive CASP = 14
Interpretive CASP = 21
Conceptual/thematic CASP = 18
Thematic survey CASP = 21
Interpretive CASP = 21
Thematic survey CASP = 20
Findings classification
and CASP total
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To describe the meanings older people aged
70 and over attach to the dynamics of hope
To identify threats to hope in people with
severe COPD
To explore and describe the meaning of hope
and social support in patients receiving
chemotherapy
To report the meaning of hope in people
living with COPD
To examine the meaning of hope from the
perspective of Chinese advanced patients
with cancer in Hong Kong
Is there a difference in level of hope between
those patients being curatively and those
palliatively treated, and how does this
change over time?
To explore the definitions and sources of
hope in patients with end-stage renal disease
receiving chronic haemodialysis
Kylma (1998) (Finland)
Matsumoto and Doi (2006) (Japan)
Mattioli et al. (2008) (USA)
Thematic/descriptive
Semi-structured interviews with 14 persons with
renal disease
Phenomenology/concept mapping
Interviews with 4 persons with multiple
diagnoses
Unclear from translation
Semi-structured interviews with 10 persons with
COPD
Thematic/descriptive
Semi-structured interviews with 14 patients with
cancer
Phenomenology
Interviews with 7 COPD patients
Content analysis
Semi-structured interviews with 17 advanced
patients with cancer
Mixed methods
HHI with a qualitative thematic analysis applied
to responses with 50 patients with cancer
Method/data collection
CASP, Critical Appraisal Skills Program; HHI, Herth Hope Index; COPD, chronic obstructive pulmonary disease.
Weil (2000) (USA)
Sanatani et al. (2008) (Canada)
Mok et al. (2010) (China)
Milne et al. (2009) (Australia)
Purpose
Source/country
Table 1 (Continued).
Thematic survey CASP = 13
Thematic survey CASP = 13
Conceptual/thematic CASP = 18
Thematic survey CASP = 22
Thematic survey CASP = 20
Thematic survey CASP = 15
Interpretive CASP = 23
Findings classification
and CASP total
W. Duggleby et al.
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Barroso’s (2007) classification based on the findings of the
studies: (a) nine were thematic survey, (b) three used
conceptual/thematic description and (c) eight used interpretive explanation. Sandelowski and Barroso suggest that
topical survey studies should be excluded from a metasynthesis: however, none of the studies reviewed was classified as
such, and thus none was excluded for this reason.
The findings from the articles were entered into NVIVO 8
software. The synthesis was guided by reading the findings
from the articles as a whole and team discussions to define the
concepts. Synthesis of the findings was achieved using
taxonomical analysis, a constant comparison grounded
theory approach and reciprocal translation (Sandelowski &
Barroso 2007). The purpose of the taxonomic analysis was to
identify important underlying concepts and conceptual relationships. The study findings were then evaluated for similarities and differences to clarify and define hope and discern
relationships among the interpreted concepts. A reciprocal
translation of the concepts was used to integrate the
metasynthesis findings through importing concepts that
further interpret and integrate the findings.
Validity
The descriptive validity for this metasynthesis, as suggested
by Sandelowski and Barroso (2007), was maintained by: (a) a
comprehensive search for literature; (b) team discussion and
decisions on search terms and inclusion criteria; (c) team
assessment of appraisal and assignment of CASP scores; (d)
communication with authors of reviewed studies for additional information; and (e) maintenance of an audit trail of
search results and decisions. The team also discussed findings
of the studies and themes until agreement was reached
through consensus.
Results
The 20 studies included in the metasynthesis had a total
sample of 305 and a mean age of 65Æ5 (SD 6Æ47). The studies
represented research conducted on hope in a variety of
different countries and populations with differing medical
diagnoses. The medical illnesses (when reported) were all life
threatening in nature. They included cancer, renal disease,
chronic obstructive pulmonary disease, stroke, and acute
myocardial infarction. As a result the context of hope for the
metasynthesis was one where participants were experiencing:
(a) uncertainty (unknown future outcomes) (Flemming 1997,
Benzein et al. 2001, Eliott & Olver 2007); (b) major
transitions (Dufault & Martocchio 1985, Flemming 1997);
(c) loss (Dufault & Martocchio 1985, Flemming 1997); and
(d) suffering (Flemming 1997, Daly et al. 1999, Duggleby &
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Hope, older adults, and chronic illness
Wright 2005, Matsumoto & Doi 2006). Hope occurred in
everyday interactions with others (Eliott & Olver 2007) and
the environment (Bays 2001). The findings (see main concepts
and references in supporting information Table S1) of this
metasynthesis were interpreted in this context.
Attributes of hope
In all the studies reviewed, hope was described as an
important psychological resource that helped participants
deal with chronic illness. Many positive attributes were
associated with hope including improved: sense of self
(Forbes 1999, Buckley & Herth 2004), feelings of control
(Flemming 1997, Duggleby & Wright 2005, Eliott & Olver
2007), relationships with others (Herth 1993, Matsumoto &
Doi 2006, Mattioli et al. 2008), and quality of life (Benzein
et al. 2001, Milne et al. 2009, Duggleby et al. 2010a).
Characteristics of hope
Several characteristics of hope were found including: (a)
dynamic or situational nature; (b) multiple co-existing types;
(c) hope objects that were desirable realistic possibilities; (d)
future-focused; and (e) involvement of choice/will. Hope was
situational as it changed in response to different conditions
(Daly et al. 1999) either increasing, decreasing or disappearing as situations changed (Eliott & Olver 2009). Multiple
types of coexisting hopes were described such as hope for
comfort, and peace, hope for their families and hope for a cure
(Dufault & Martocchio 1985, Benzein et al. 2001, Duggleby
et al. 2010a). The objects of hope, or what participants were
hoping for were realistic (Dufault & Martocchio 1985, Bays
2001) and desirable possibilities (Dufault & Matocchio, Eliott
& Olver 2009, Duggleby & Wright 2005).
Hope was future focused within the concept of refocused
time. Herth (1993) described refocused time as time that is not
focused on clock hours, but linked to objects of hope.
Refocused time was also described in other studies as redefined
future in which future was defined as moments or hours and/or
non-specific (Dufault & Martocchio 1985, Herth 1993,
Duggleby & Wright 2005). Hope was a choice (Duggleby &
Wright 2005), involved will (Daly et al. 1999) and was a neverending process (Forbes 1999, Duggleby & Wright 2005).
Transcendence
Transcendence was one of the two main overlapping processes
emerging from the data. The results of the studies reflected the
transcendence of older persons with chronic illness beyond
their difficult present. For example, several of the studies used
the word transcending in their findings (Dufault & Martoc1217
W. Duggleby et al.
chio 1985, Flemming 1997, Forbes 1999, Benzein et al. 2001).
In other studies, transcendence was referred to as moving
beyond their current state (Herth 1993, Eliott & Olver 2007,
Mattioli et al. 2008), or moving forwards (Bays 2001). The
process of transcending involved the sub-processes of reaching
inwardly and outwardly and finding meaning and purpose.
Reaching inwardly and outwardly
Herth (1993) suggested that older persons have a perceived
sense of linking within and without the self (with others).
There was an inner strength or core that persons with longterm disease reach for to maintain their hope (Herth 1993,
Bays 2001). This ‘inward self’ involved beliefs and past
experiences and uplifting memories (Herth 1993). It also included a positive outlook or optimistic approach (Herth
1993, Duggleby & Wright 2005).
As well as reaching inwardly, older persons with chronic
illness reached out to connect with family and friends,
healthcare professionals, nature, and a higher power (Daly
et al. 1999, Duggleby & Wright 2005, Matsumoto & Doi
2006, Mattioli et al. 2008, Eliott & Olver 2009). Positive
supportive relationships with others were important for this
process to occur. Reaching out and connecting with others
increased their awareness of others and their environment
and helped them take on a broader perspective of what
was happening to them (Eliott & Olver 2009). For
example, they focused less on themselves and more on
others (Eliott & Olver 2009). It was through this inwardly
and outwardly reaching that older persons with chronic
illness began their search for positive meaning and purpose
in their life.
Finding meaning and purpose
Several studies described searching for meaning and purpose
as an important process of hope. The process of searching for
meaning for older persons with chronic illness involved
reflecting upon what was important to them and examination
of their values and priorities (Dufault & Martocchio 1985,
Benzein et al. 2001, Davison & Simpson 2006). Finding
meaning helped to define what was of value and a priority in
their life (Benzein et al. 2001, Duggleby & Wright 2005,
Davison & Simpson 2006). Examples of priorities included
returning to normal (as much as possible) (Benzein et al.
2001, Mattioli et al. 2008, Sanatani et al. 2008, Mok et al.
2010), maintaining positive health outcomes (not suffering)
(Daly et al. 1999, Duggleby & Wright 2005, Sanatani et al.
2008) and maintaining relationships with others (Duggleby
& Wright 2005, Sanatani et al. 2008). The relationship of
finding positive meaning and purpose to hope is best
described by a study participant with chronic renal disease:
1218
‘… you’ve still got something to do in your life and your hope
is to get it done.’ (Weil 2000, p. 220).
Positive reappraisal
The process of positive reappraisal was also a major process
evident in the findings and included subprocesses of
re-evaluating hope and seeing positive possibilities.
Re-evaluating hope in light of illness
Findings of several of the studies made reference to persons
with chronic illness recognizing that their situation had
changed as a result of their chronic illness (Flemming 1997,
Forbes 1999, Duggleby & Wright 2005, Mattioli et al. 2008,
Eliott & Olver 2009). With this recognition and acknowledgement they began the re-evaluation of previous hope in
light of their chronic illness (Flemming1997, Forbes 1999).
With this re-evaluation there was loss of some hopes (Dufault
& Martocchio 1985, Forbes 1999, Duggleby & Wright 2005,
Eliott & Olver 2009) or leaving old hopes behind (Forbes
1999, Milne et al. 2009).
Seeing positive possibilities
Seeing positive possibilities was reflected in all the studies
where persons with chronic illness, even those who were
dying, were able to perceive positive aspects of their future.
This refers to the essence of hope as possibilities of a better
future. There was an acknowledgement that both negative
and positive possibilities may occur, but there was a choice to
focus on the positive (Eliott & Olver 2007). This resulted in
the possibility of different kinds of hope (Milne et al. 2009),
or new hopes emerging (Forbes 1999, Duggleby & Wright
2005).
Hope: transcending possibilities
Conceptually integrating the processes of transcendence and
positive reappraisal illustrates the interrelationships of these
concepts. In Figure 2, the outer circle reflects the context of
the physical and psychosocial environment, uncertainty, loss,
and suffering in which hope occurs. The dynamic nature of
the two processes and their relationship with each other is
represented by the lines between the two concepts. For
example the re-evaluation of hope in the light of illness is
influenced by the transcendence subprocess of reaching
inwards and outwards and finding purpose and meaning as
they determine priorities of hope which, in turn, provides a
new structure to evaluate hope. This new structure may be
based on prioritizing hope for peace and comfort rather than
hope for a cure. The re-evaluation of hope triggers the need
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Hope, older adults, and chronic illness
ical
Phys
and psychosocial environm
e nt
Transcendence
Positive reappraisal
Re-evaluation of hope
Reaching inward and outward
Seeing positive possibilities
Finding meaning and purpose
Figure 2 Transcending possibilities.
for the transcendence processes to occur as old hopes are lost.
The process of hope for an older person with chronic illness is
an unending process.
Discussion
Limitations
There are several limitations to this study. The articles
included in the metasynthesis represented various contexts
and cultures. As such, the contextual and cultural nuances
(particularly through translation) may have been lost.
However, the intent of ensuring diversity adds to the global
nature of the understanding of the concept of hope in older
adults with chronic illness. Another limitation is that
assumptions made by the authors of the studies are continued
in the metasynthesis, as the findings and not actual data are
synthesized. Another limitation is the variety of methodological approaches used in the included studies. The findings of
the different studies reflect these approaches, which also have
differing philosophical assumptions. In addition, the metasynthesis reported findings from studies of older persons with
chronic illnesses with a wide range of illnesses. Although the
studies reflected similar concepts, such as hope is situational
and is influenced by the illness experience, the findings may
be different if the metasynthesis focused on one illness only.
The life-threatening nature of the illnesses may have influenced the findings as well. Future research should be
conducted about the hope of persons with chronic illnesses
that are not life threatening.
2012 Blackwell Publishing Ltd
Findings
The major findings of this metasynthesis study are the two
inter-related processes of transcendence and positive reappraisal. Although these findings are significantly different
from other hope metasynthesis studies, they give more clarity
about some of these previous findings. For example, Wiles
et al. (2008), found a lack of clarity around whether hope
was a want or hope was an expectation. For persons with
chronic illness, during the process of transcendence, they
identified what was most important or desirable to them
which became the focus of their hope. In this way hope was
something that was desirable or wanted. The process of
positive reappraisal identified what was realistically possible
through evaluation of their situation and finding possibilities.
Thus in essence, hope is desirable (wanted) possibilities.
Six dimensions of hope were articulated in the metasynthesis study of the meaning of hope in nursing research
(Hammer et al. 2009): living in hope, hoping for something,
hope as a light on the horizon, hope as a human to human
relationship, hope vs. hopelessness, and hope as weathering a
storm. These dimensions reflect the transcendence and
positive reappraisal of hope found in our metasynthesis. For
example, hope as weathering a storm may be a reflection of
the transcending nature of hope from a difficult present
(suffering) to a positive future. Hope as a light on the horizon
refers to the positive nature of hope for a better future. Living
in hope and hope as a human to human relationship may
reflect the inward and outward searching and finding
meaning and purpose that were aspects of the transcendence
1219
W. Duggleby et al.
What is already known about this topic
• Hope helps persons with chronic illness deal with their
illness.
• Hope changes in different situations.
• Hope has many dimensions.
What this paper adds
• Hope in older persons with chronic illness involves
transcendence from a difficult situation and positive
reappraisal.
• Transcendence involves reaching inwardly and
outwardly to others and finding meaning.
• Positive reappraisal involves evaluating hope in the light
of illness and finding positive possibilities.
Implications for practice and/or policy
• Assessment of the hope of older adults with lifethreatening illness should include the processes of
transcendence and positive reappraisal.
• Fostering the inner strength and relationships with
others may help engender hope.
• Strategies such as adjustment to transitions and losses,
life review, reminiscence therapy and spiritual support
may also help people find hope.
of hope. The existential nature of hope (living in hope) is
evident in the inward searching and finding meaning and
purpose. Outward searching and connecting is an important
aspect of hope as human to human relationship. The
importance of connecting with others and or a higher power
as a process in hope possibly explains why faith, families,
friends, and healthcare professionals were described as being
a source of hope in several of the studies of older persons with
chronic illness. Through the process of finding meaning and
purpose, what was of value and a priority for hope is the
foundation of the object of hope, and the dimension of
hoping for something. Hoping for something also involves
the process of positive reappraisal, as it is through seeing
possibilities, that a person can have something to focus their
hope upon.
Positive reappraisal was an integral part of the conceptual
model developed by Duggleby et al. (2010b) in their metasynthesis study of hope of family members of persons with
chronic illness. They described appraisal of the conditions of
hope and the uncertainty that their hope was achievable.
Similar to persons with chronic illness, this appraisal also
1220
included awareness of changes in conditions. Cognitive
reappraisal theory suggests that an individual’s subjective
appraisal of an event and positive reframing of the event,
changes their consequent emotional response (Lazarus &
Folkman 1984, Gross 1998). As a result reappraisal decreases
stress and depression and is associated with positive health
outcomes (Troy et al. 2010). Duggleby et al. (2010b) suggest
that the hope of family members of persons with chronic
illness results in positive health outcomes. This is similar to
the findings of the metasynthesis of hope in persons with
chronic illness. The positive reappraisal process may be one
explanation for the positive relationship between hope and
health.
Transcendence is linked with positive health and well
being (Reed 2008, p. 108). Transcendence is moving
beyond one’s current situation to a broader awareness of
others and the environment (Reed 2008). Frankl (1963)
suggests that transcendence involves the processes of
reaching inwardly and outwardly and finding meaning
and purpose. Although these processes were found in the
hope studies of persons with chronic illness they were not
described in Duggleby et al.’s (2010b) metasynthesis findings of hope of family carers of persons with chronic illness.
Reasons for these differences may include: (a) the hope of
family caregivers vs. the hope of persons with chronic
illnesses, (b) the age of the person (younger vs. older
adults), and (c) experiences associated with suffering and
awareness of personal mortality. In a qualitative study of
family carers of persons with dementia, Acton (2002) found
little evidence of transcendence. She suggested carers have
little opportunity to engage in transcendence activities
because of their social isolation, ambivalence and burden
of care. Another reason maybe that the Duggleby et al.’s
(2010b) metasynthesis study included qualitative studies of
family carers of all ages (mean age of 47) and did not focus
on older adults. Gerotranscendence theories suggest that
self-transcendence views and behaviours are characteristic
of older adults (Tornstam 1996, Reed 2008). Thus, the
focus on older adults with chronic illness may explain the
finding of transcendence. However, Reed (2008), p. 105)
suggests that transcendence occurs in any situation where a
person feels an awareness of their personal mortality. More
research on the potential differences in the hope experience:
(a) with different age groups and (b) family carers and
persons with chronic illness is needed to understand if
differences exist.
The studies of persons with chronic illness included in this
hope metasynthesis, described their participants as suffering
and dealing with chronic illnesses that were life threatening.
It is possible that hope changes in interaction with suffering.
2012 Blackwell Publishing Ltd
JAN: REVIEW PAPER
Suffering is the experience of deep physical, emotional, and
existential pain and distress (Kahn & Steeves 1986). For
persons experiencing chronic illness, suffering is the loss of
self and meaning and purpose in life (Charmaz 1983) and is
not unique to older adults. Future research should focus on
exploring the relationships between hope and suffering of
persons with chronic illnesses.
The emerging conceptual model of hope as an integration
of transcendence and positive reappraisal adds to our understanding of the complex dynamic nature of hope. It explains
why hope of older persons with chronic illness may differ
from other populations and why studies that include participants with diverse age ranges may have mixed findings on
hope. It also explains some of the variation found in current
theories of hope. For example, Synder’s (2000) theory of hope
focuses on cognitive reappraisal and goal setting as it was
conducted with students, whereas Duggleby and Wright’s
(2005) emerging theory was conducted with older palliative
care patients. The emerging conceptual hope model ‘Transcending Possibilities’ suggests the possibility of different hope
processes for older persons with chronic illness compared to
relatively healthy younger students. Most importantly, the
findings of this metasynthesis further our understanding of the
nature and importance of relationships with others and
spirituality. An important aspect of transcendence is reaching
inwardly (drawing on inner strength) and outwardly to
others; having hope may be difficult without inner strength
to drawn upon and in isolation from others.
Hope, older adults, and chronic illness
transcend their experience of suffering. Hope is maintained
through relationships with family, friends, healthcare professionals, and spiritual connections. Thus, assessment of hope
and strategies to foster hope should include ways to maintain
relationships and spiritual connections. The finding of hope as
an important psychological resource of persons with chronic
illness to help deal with their experience, underscores the value
of finding ways to engender hope in this population.
Funding
Funding for this study was provided by University of Alberta
Faculty of Nursing Establishment Grant.
Conflict of interest
No conflict of interest has been declared by the authors.
Author Contributions
WD, CN, LH, AW, and TC were responsible for the study
conception and design. WD, DH, and TC performed the data
collection. WD, DH, CN, LH, AW, and TC performed the
data analysis. WD and DH were responsible for the drafting
of the manuscript. WD, DH, CN, LH, AW, and TC made
critical revisions to the article for important intellectual
content. DH provided administrative, technical or material
support.
Conclusion
Supporting Information Online
The findings from this study provide a unique way of thinking
about the concept of hope, through the lens of ageing and
chronic illness, based on participants’ experiences. Hope is
integrated with an older persons’ illness experience in
important multidimensional and diverse ways. For example,
hope for older persons with chronic illness may change based
on its interactions with suffering with two interrelated
processes of transcendence and cognitive appraisal. As such
conceptual frameworks of gerotranscendence in combination
with cognitive reappraisal may be useful to guide future
research about hope.
Hope, as a concept, may differ for older adults than for
younger adults, which adds important insight into the tailoring
hope interventions for this population. For example, ways to
foster hope with older adults with chronic illness may include
strategies for finding meaning and purpose which is a process
of transcendence. Strategies such as adjustment to transitions
and losses, life review, reminiscence therapy, and spiritual
support can help people find meaning and purpose, and
Additional Supporting Information may be found in the
online version of this article:
Table S1. Main Concepts and Specific References.
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials supported by the authors. Any queries (other than missing
material) should be directed to the corresponding author for
the article.
2012 Blackwell Publishing Ltd
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